See New York State’s Compliance Library and CMS’ Medicaid Integrity Education for certain state and federal requirements.
Our Enhanced Care Prime Network providers must meet the following requirements to be able to treat our Medicaid and HARP members.
Medicaid Cultural Competency Training Certification
Each year, the New York State Department of Health requires Enhanced Care (Medicaid Managed Care) and Enhanced Care Plus (HARP) providers to certify completion of cultural competency training for all staff who have regular and substantial contact with EmblemHealth members. To satisfy this training requirement, provider staff must complete the U.S. Department of Health & Human Services e-learning program and submit a certification.
Informed Consent Required for Medicaid Hysterectomy/Sterilization
Federal regulations require Medicaid patients’ consent to hysterectomy and sterilization procedures. A signed consent form must be submitted for the claim to be processed.
Compliance: Home Care Worker Wage Parity Law
By Dec. 1, 2023 New York State law requires the following entities to complete and submit an annual certification of compliance with the Home Care Worker Wage Parity Law—Public Health Law § 3614-c—to the New York State Department of Health via the Provider Portal at emedny.org:
- Certified Home Health Agencies (CHHAs)
- Licensed Home Care Services Agencies (LHCSAs)
- Consumer Directed Personal Assistance Program Fiscal Intermediaries (FIs)
Additionally, by Nov. 30, 2023, all contracted LHCSAs and FIs must complete and submit the Department of Labor form LS300 “Annual Compliance Statement of Wage Parity, Hours, and Expenses” for calendar year 2022, and for 2021 if not already submitted last year, to EmblemHealth via email at wageparity@emblemhealth.com: Please note:
- If you are contracted as both a LHCSA and an FI, submit separate forms.
- If any revisions to the form are made, they will take effect for the 2023 calendar year forward.
- The form due date for calendar year 2023 will be announced in 2024.
These requirements apply to our network providers who deliver home care services to EmblemHealth Medicaid, HARP, and/or CHPlus members in New York City, Nassau, Suffolk, and/or Westchester counties.
The due date for independently audited financial statements verifying wage parity expenses for calendar years 2021 and 2022 will be announced at a later time.
If you have questions, please sign in to our secure provider portal and use the Message Center to send your inquiry.
Medicaid Provider Disclosure of Ownership and Control
The New York State Department of Health requires written disclosure regarding ownership, control, and criminal convictions related to certain controlling persons’ involvement in Medicare, Medicaid, or Title XX programs. Specifically:
- Section 42 CRF455.104 ‒ Requires managed care organizations, like EmblemHealth, to collect the disclosure of complete ownership, control, and relationship information from certain entities identified in the statute. These include:
- all participating hospitals,
- skilled nursing facilities,
- home health agencies,
- independent clinical laboratories,
- renal disease facilities, and
- any entity (other than an individual practitioner or group of practitioners) who furnishes or arranges for health-related services for which it provides claims payment under any plan or program established under Title V or Title XX of the Social Security Act.
- Section 42 CRF455.106 ‒ Requires managed care organizations, like EmblemHealth, to collect and report health care-related criminal conviction disclosure information (initially and upon renewal of their contracts) of any managing employee who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or a Title XX program.
Disclosure forms must be completed and submitted as part of the credentialing and recredentialing processes. This applies to both directly contracted providers and delegated entities. Disclosure forms must also be submitted when a reportable event occurs and upon request of the New York State Department of Health and EmblemHealth.
Required Annual Compliance Certification: Office of the Medicaid Inspector General Certification process: If you are a Medicaid provider, you are likely required to adopt and maintain an effective compliance program. Further, you will now need to attest to your compliance as part of your annual “Certification Statement for Provider Billing Medicaid.” This annual certification shall occur on the anniversary date of the provider’s enrollment in Medicaid.
Finding anniversary date: According to the NYSDOH, “Providers can find their anniversary dates on their initial Medicaid enrollment welcome letters. Additionally, each year, approximately 45-60 days before the anniversary of a provider’s enrollment, the NYS Department of Health (NYSDOH) sends by mail a package of information and materials to the provider, which includes the Certification of Statement for Provider Billing Medicaid Form. This form must be completed and returned to the NYSDOH by the enrollment anniversary date.”
Why you need to certify: With regard to the Social Services Law (SSL) certification, New York State’s (NYS’s) mandatory compliance program law applies to Medicaid providers subject to Public Health Law (PHL) Articles 28 or 36, or Mental Hygiene Law (MHL) Articles 16 or 31, regardless of the amount they bill, order, or receive from NYS’s Medicaid program. Plans will need to monitor network provider compliance with the SSL certification requirement.
Who should certify: In addition, a compliance program is required for other persons, providers, or affiliates who provide care, services, or supplies under the Medicaid program, or who submit claims for care, services, or supplies for or on behalf of another person for which Medicaid is, or should be reasonably expected by the provider to be, a substantial portion of their business operations as follows:
1. A person, provider, or affiliate who claims, orders, has claimed or ordered, or should be reasonably expected to claim or order at least $1,000,000 in any consecutive 12-month period from Medicaid;
2. A person, provider, or affiliate who receives, has received, or should be reasonably expected to receive at least $1,000,000 in any consecutive 12-month period directly or indirectly from Medicaid or a Medicaid Managed Care Plan; or
3. A person, provider, or affiliate who submits or has submitted claims for care, services, or supplies to the Medicaid program on behalf of another person or persons in the aggregate of at least $1,000,000 in any consecutive 12-month period.
What the compliance program should include: The law and regulations contain a set of seven minimum core elements applicable to all providers, regardless of size. However, the law also recognizes compliance programs should reflect the provider’s size, complexity, resources, and culture as long as the compliance program meets the requirements.
Available resources: The Office of the Medicaid Inspector General (OMIG) suggests Medicaid providers review OMIG’s published Compliance Guidance, Medicaid Updates, and Compliance Alerts, among other OMIG publications and outreach methods, for information on how to meet NYS mandatory compliance program requirements. There is a Compliance Library on OMIG’s website to guide providers in developing and implementing an effective compliance program. Medicaid providers are encouraged to subscribe to OMIG’s listserv. The listserv provides an email notification of any changes to OMIG’s website, including changes to published compliance program-related materials.
JP# 64939 03/2024